Request For Medicare Prescription Drug Coverage Determination Form printable pdf download

Request For Medicare Prescription Drug Coverage Determination Form

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION

This form may be sent to us by mail or fax:

Address:

Fax Number:

Blue Cross Blue Shield of New Mexico

1-877-302-9807

Lovelace Medicare Plan (HMO / HMO-POS)

Pharmacy Department

4411 The 25 Way Suite 300

Albuquerque, NM 87109

You may also ask us for a coverage determination by phone at Toll Free: 1-877-895-6448

TTY/TDD: 711. We are open 8 a.m. – 8 p.m., local time, 7 days a week. If you are calling from

February 15 through September 30, alternate technologies (for example, voicemail) will be used on

weekends and holidays, or through our website at

Who May Make a Request: Your prescriber may ask us for a coverage determination on your

behalf. If you want another individual (such as a family member or friend) to make a request for

you, that individual must be your representative. Contact us to learn how to name a representative.

Enrollee’s Information

Enrollee’s Name _____________________________________

Date of Birth _______________

Enrollee’s Address _______________________________________________________________

City ___________________________ State______________ Zip Code _______________

Phone ___________________________ Enrollee’s Member ID # __________________________

Complete the following section ONLY if the person making this request is not the enrollee

or prescriber:

Requestor’s Name ____________________________________________________________

Requestor’s Relationship to Enrollee _____________________________________________

Address ____________________________________________________________________

City __________________________________ State ________ Zip Code ______________

Phone _____________________________

Representation documentation for requests made by someone other than enrollee or the

enrollee’s prescriber:

HMO and HMO-POS plans are provided by Blue Cross and Blue Shield of New Mexico, a Division

of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent

Licensee of the Blue Cross and Blue Shield Association. HCSC is a Medicare Advantage

organization with a Medicare contract. Enrollment in HCSC’s plans depends on contract renewal.

Y0096_APG_MAPDNMCDReqForm16b

Request For Medicare Prescription Drug Coverage Determination Form